Dimensions of Health and Health Promotion.

NORDENFELT, Lennart and Per-Erik LISS (Eds.)
Amsterdam/New York, NY, 2003, xv, 225 pp.

Series:
Value Inquiry Book Series 138

"Nordenfelt [is] one of the most famous experts on philosophy of health and on questions of health care …the book overall raises some very interesting questions and discusses them on a high level … a very valuable read"
Medicine, Health Care and Philosophy, Vol. 6, No. 3, 2003

This book contains scholarly contributions to several current debates in the philosophy of medicine and health care regarding the nature of health and health promotion, concepts and measurements of mental illness, phenomenological conceptions of health and illness, allocation of health care resources, criteria for proper medical science, the clinical meeting, and ethical constraints in such a meeting.
With one exception, the authors in this book are or have been teachers or graduate students at the interdisciplinary Department of Health and Society (Tema H) at Linköping University, Sweden. While all the texts have a philosophical focus, many other disciplines have influenced the choice of specific perspectives. The university backgrounds of the authors range from medicine, psychology, sociology, and religion to philosophy. What binds the authors together is their deep interest in the theory of medicine and in the pursuit of a philosophy of humanistic medicine and health care.

Contents:
Foreword by Ingmar Pörn
Editors’ Preface
Part One Characterizations of Health and the Good Life
ONE Bo PETERSSON: Health, Doctors, and the Good Life: A Footnote to Plato
TWO Per SUNDSTRÖM: Health as Metaphor and as Metonymy – An Exploration
THREE Lennart NORDENFELT: An Evolutionary Concept of Health: Health as Natural Function
Part Two Concepts and Measurements of Mental Health. The Context of Psychotherapeutic Treatment
FOUR Einar JAKOBSSON: Health, Psychopathology, and the Action of the “Talking Cures”
FIVE Per-Anders TENGLAND: A Conceptual Approach to Measuring Psychiatric and Psychotherapeutic Treatment
Part Three Health and Illness from a Phenomenological Point of View
SIX Jennifer BULLINGTON: Health as Receptivity: A Phenomenological Interpretation of Allostasis
SEVEN Fredrik SVENAEUS: A Phenomenological Analysis of the Concepts Handicap and Illness
Part Four Health and Health Promotion from the point of view of family medicine, medical genetics and the care of the elderly
EIGHT Olle HELLSTRÖM: Health and Dialogue-Based Medicine
NINE Kristin ZEILER: Transgressive Technologies in Reproductive Medicine: Do They Call for a Revision of Notions of Health?
TEN Bengt RICHT: Old, Ill and Estranged: On the Needs of Persons Receiving Elderly Care
Part Five Constraints on Interventions: Scientific and Ethical Requirements
ELEVEN Per-Erik LISS: Allocation of Scarce Resources in Health Care: Values and Concepts
TWELVE Ingemar NORDIN: Quackery
THIRTEEN Nina NIKKU: Private Life: Sketching Entrances for Ethical Analysis
Works Cited
About the Contributors
Index

ABOUT THE CONTRIBUTORS

Jennifer Bullington, Ph.D., is a researcher at The National Institute for Psy-chosocial Factors and Health, Stockholm. Bullington has an academic back-ground in philosophy (B.A.) and psychology (M.A.) and a clinical back-ground as a physiotherapist and body-oriented psychotherapist. She defended her dissertation, The Mysterious Life of the Body: A New Look at Psycho-somatics, in 1999 at the Department of Health and Society at the Uni-versity of Linköping, Sweden. Her main areas of research interest are phe-nomenology and psychosomatic studies. She has participated in a number of empirical studies that employed a phenomenological method. Her current research concerns the care and treatment of psychosomatic patients with psychiatrics and general practice.

Olle Hellström, M.D., Ph.D., is a general practitioner at Vansbro Health Care Unit in the county of Dalarna, Sweden, where he participates in the education of doctors training to become family physicians. He is also a Research Fel-low in the Center for Clinical Research in the city of Falun, Sweden. He has contributed to several anthologies about the interface between medicine and philosophy, published the book, What Illness Will Tell, and contrib-uted richly to the Journal of the Swedish Doctors’ Association. His main practical and research interest are doctor-patient relationships, dia-logue-based medicine, and phenomenology.

Einar Jakobsson, Ph.D., is a psychologist, specialist in clinical psychology, and Senior Lecturer at Mälardalen University in Västerås and Eskilstuna, Sweden. In addition to psychotherapy research, he is at present carrying out research in children’s health, professional intervention, and family coopera-tion in health care.

Per-Erik Liss, Ph.D., is Associate Professor at the Department of Health and Society, Linköping University. He has a background in philosophy and re-ceived his doctoral degree at the Department of Health and Society in 1990. He has a particular interest in the field of setting priorities in health care; his main publication in this field is Health Care Need (1993).

Nina Nikku, Ph.D., is Assistant Professor at the Tema Institute, Linköping University, and Lecturer at Jönköping University. She received her doctoral degree in 1997 from the Department of Health and Society, Linköping Uni-versity, where she defended the thesis . Her recent research concerns ethics in the health care sector as well as the relation between ethics and politics.

Lennart Nordenfelt has been Professor of Philosophy of Medicine and Health Care at the Department of Health and Society, Linköping University, since 1987. He received his doctoral degree in theoretical philosophy at the Uni-versity of Uppsala in 1974 and was subsequently appointed a lecturer in theoretical philosophy at the University of Stockholm. Nordenfelt has made contributions mainly to action theory, the theory of medicine, and the theory of health and welfare. His monographs include On the Nature of Health (1987 and 1995) and Action, Ability, and Health (2000).

Ingemar Nordin, Ph.D., is Professor of Philosophy at Linköping University’s Department of Health and Society. His fields of research are the philosophy of science and technology, political philosophy, and the philosophy of medi-cine. He is especially interested in the problems of knowledge and rationality within medical research and practice. His main publications in the field are “The Role of Science in Medicine” in Theoretical Medicine and Bio-ethics, No. 3, Vol. 20, 1999, and “Expert and Non-Expert Knowledge in Medical Practise,” in Medicine, Health Care, and Philosophy, No. 3, Vol. 3, 2000.

Bo Petersson is Professor of Practical Philosophy at Linköping University. He received his doctoral degree in practical philosophy at Uppsala University in 1973. His main research interests are within research ethics, moral phi-losophy, and the history of philosophy.

Bengt Richt, Ph.D., is Associate Professor at the Department of Health and Society, Linköping University, where he obtained his doctoral degree through a study of the living situation of juvenile diabetics and their families. His research interest is the sociology of health and illness, with special em-phasis on the phenomenology and social psychology of chronic illness and on lay conceptions of health, illness, and health care, including complemen-tary medicine. He has carried out research on elderly care and has recently published a book in Swedish about contact persons in elderly care. He is also involved in a study of the local implementation of a governmental program for health-promotion.

Per Sundström, born in 1955 in Stockholm, studied philology, philosophy, and theology at Uppsala University. He received his M.D. degree from the Karolinska Institute, Stockholm, and earned a Ph.D. in the philosophy of medicine at Linköping University. He is currently Professor of Medical Eth-ics on the Medical Faculty of the University of Oslo, Norway.

Fredrik Svenaeus, Ph.D., is Assistant Professor in Philosophy at Södertörn University College, Huddinge, Sweden. His main research interests are the phenomenology of medicine, philosophy of psychiatry, and bioethics. He defended his doctoral dissertation at the Department of Health and Society, Linköping University, in 1999. That thesis was recently published in a sec-ond, revised edition: The Hermeneutics of Medicine and the Phenome-nology of Health: Steps Towards a Philosophy of Medical Practice (Kluwer, 2001).

Per-Anders Tengland, Ph.D., is a Senior Lecturer at the Department of Public Health at Malmö University, Sweden. He received his Ph.D. from the De-partment of Health and Society at Linköping University. Kluwer Academic Publishers has published a revised version of his doctoral thesis under the title Mental Health: A Philosophical Analysis (2001). Lately Teng-land has taken an interest in the theoretical foundations of psychotherapy, writing about the concepts of “congruence” and “empathy.”

Kristin Zeiler, M.A. (in medicine and religious sciences), is a Ph.D. candidate at the Department of Health and Society, Linköping University. Her study Lifeviews, Human Nature, and Genetics aims at exploring moral questions as discussed by gynecologists and geneticists in Sweden, Italy, and the United Kingdom in the context of preimplantation genetic diagnosis and germ-line gene therapy. Her main areas of interest are bioethics, feminist ethics, global/ecumenical ethics, and research on life views. The research reported in her essay was financially supported by the Swedish Foundation for International Cooperation in Research and Higher Education (STINT).

FOREWORD

For several years I had the pleasure and privilege of following at close range the work of the Department of Health and Society at Linköping University. I participated as a partner in many dialogues with research students and as a participant in advanced seminars.
My engagement was as a philosopher. Therefore, my main concern was with the philosophical section of the Department. Its genuine interdiscipli-nary approach impressed me in several ways: Old and new problems ap-peared together; in this process the need to promote variety in choice of sub-ject, style, and research tradition became apparent; and, undoubtedly, the researchers worked hard to respond to that need. They have now made some of this work available in the form of a selection of essays.
I hope that this book will give readers reasons to reflect on conceptual matters in the field of health conceptions and health-promotion. One of my reflections throughout has been that doing what is sometimes misleadingly called applied philosophy is a challenging task that can yield interesting results. I also hope that the book will give practitioners in the field reasons to reflect on the advantages of exploring different approaches to topics of abid-ing concern to them.

Ingmar Pörn
Emeritus Professor of Philosophy
University of Helsinki

EDITORS’ PREFACE

The Department of Health and Society (Tema Hälsa och samhälle, Tema H) at Linköping University, Sweden, started in 1981. The idea behind the Tema-Institute, of which Tema H formed a part, was to conjoin representatives from different disciplines to focus their research and teachings on specific areas (“temas”). Health and health care were the subjects the Institute chose for Tema H. This became the research platform for a small faculty of econo-mists, sociologists, philosophers, historians, and an epidemiologist interested in health matters.
This book reflects some concerns and research results of Tema H’s phi-losophical section. With one exception, the authors in this book are or have been teachers or graduate students at Tema H. The exception, Dr. Olle Hell-ström, is a primary care doctor who has taken part in many seminars and other academic activities in the department.
Our references to the philosophical section of Tema H are a simplifica-tion. Since the Department is interdisciplinary, no sharp borders exist be-tween the subjects. Some authors in this volume have no academic philoso-phical training. Our university backgrounds range mostly from medicine, psychology, sociology, and religion to philosophy. Binding us together is our deep interest in the theory of medicine and the pursuit of a philosophy of humanistic medicine and health care.
A quick glance at the contents of this book shows that our main concern is the clarification of central concepts related to health care, especially the concept of health. This concern quite well reflects the general focus of the Tema H research. Since the publication of Lennart Nordenfelt’s On the Na-ture of Health (1987, 2nd edit., 1995), several dissertations in the department have dealt with the notion of health, be it somatic or mental: Tommy Svens-son, On the Notion of Mental Illness (1990); Per-Erik Liss, Health Care Need (1990); Einar Jakobsson, Psykoterapins uppgift [The Aim of Psychotherapy] (1994); Per-Anders Tengland, Mental Health: A Philosophical Analysis (1998, 2002); Fredrik Svenaeus, The Hermeneutics of Medicine and the Phe-nomenology of Health (1999, 2001); and Jennifer Bullington, A New Look at Psychosomatics (1999). Differences exist between our detailed analyses of health. We come together, however, in a common holistic outlook on the concept and in setting the goal of medicine on the level of the capability and well-being of the whole human being.
Some of the treatises published at Tema H emphasize aspects of the the-ory of health outlined by Nordenfelt in 1987. This theory has a place in the tradition of the American Caroline Whitbeck, the Finn Ingmar Pörn, and the Englishman K. W. M. Fulford. A central idea in this tradition is that health consists of a special kind of ability; in Nordenfelt’s terms, an ability to real-ize the subject’s vital goals given standard or accepted circumstances. Dis-eases, injuries, and defects are viewed as the typical causes of a reduction of the ability that constitutes health. Liss explicitly bases his analysis of health care need on this characterization of health, and Tengland develops a theory of mental health on the same ground. Other authors in the department have discussed this notion in their treatises, but have had other foci (Svensson) or chosen to develop ideas in a slightly different direction (Svenaeus). In this volume, the concept of health is the primary concern for Nordenfelt, Sund-ström, Bullington, and, from a historical point of view, Petersson.
Also, some negative medical concepts, such as illness, disease, and handicap, have attracted the academic interest of many of us. Sundström’s Icons of Disease (1987) is a thorough analysis of central concepts of disease in the spirit of Paul Ricoeur. Mental illness comes to the fore in Svensson’s treatment. Psychosomatic illness is the focus in Bullington’s dissertation. Disease and illness and the relation between the two, from the point of view of the clinician, constitute the main topic in Hellström’s writings on the phi-losophy of medicine. Svenaeus, in this volume, pursues an analysis of the relation between the notions of handicap and illness.
We might note that some of the sociologists of Tema H—in particular Bengt Richt and Gunilla Tegern—are pursuing research on lay conceptions of health and illness partly using the philosophical models as tools for analy-sis and paradigms for comparison. Richt’s contribution to this volume is an example of the sociologist’s concern.
The philosophical discussion of health promotion, quality of life, priority-setting, and the setting of goals for medicine and health care are other central topics at Tema H. They came to the fore when Tema H, in 1993, became part of the broad international research program called The Goals of Medicine. The director of the Hastings Center for Ethics in New York, Daniel Callahan, gathered representatives from 15 countries to consider issues concerning the goals and priorities in medicine. One central issue in these considerations was how to characterize the nature of health and quality of life—and their place as a goal in medicine. The main result of this program was the publica-tion of the book, The Goals of Medicine: The Forgotten Issues in Health Care Reform (1999) to which two of the present authors contributed. A fur-ther event that triggered research and philosophical considerations in this area was the Swedish governmental report—and later a law—on prioritiza-tion in health care. Members of Tema H have been active in responding to these documents. The notion of quality of life and its relation to health and health care is an issue treated in Nordenfelt’s Concepts and Measurement of Quality of Life in Health Care (1994) and in Ragnar Furenhed’s dissertation, En Gåtfull Verklighet [Puzzling Reality], (1997). In the present volume, our interest in health promotion, quality of life, and goal-setting is most clearly visible in the contributions by Liss, Jakobsson, Zeiler, and Tengland.
Some of the texts produced by authors in the Tema H group explicitly or implicitly deal with issues in the philosophy of medical science and health care. Many of our conceptual analyses have implications for the science and the practice of medicine. We have highlighted questions of scientific meth-odology and requirements to make with regard to the scientific support of medical treatments. Reflections on these issues come to the fore in quite different ways in Henrik Belfrage’s Psykiskt störda brottslingar [Mentally Disordered Offenders] (1989) and Elisabeth Wärnberg Gerdin’s Nordisk samhällsodontologi [Nordic Community Dentistry] (1994). In this volume, Ingemar Nordin’s article on quackery reflects this concern.
Questions of ethics, in particular the issue of what characterizes the good practice of medicine, have always been present, although not always the primary focus, in our writings. Svenaeus analyzes the concept of the good clinical meeting in his dissertation and in later works. All of Hellström’s writings and Svenaeus’s Sjukdomens mening [The Meaning of Disease] dis-cuss the ethical requirements on the clinician, not least in view of a holistic concept of health. Sundström is the author of a textbook in medical ethics, Sjukvårdens etiska grunder [The Ethical Foundations of Health Care]. The ethics of health promotion is the topic of Nina Nikku’s Informative Paternal-ism (1997); ethical and legal aspects of abortion are treated in Jan Perselli’s Fostersyn i svensk rätt [The Perception of the Fetus in Swedish Law]; and the ethics of the new technologies of reproduction is the issue in Kristin Zeiler’s forthcoming dissertation. In this volume, the ethical concern is salient in the contributions by Hellström, Nikku, and Zeiler.
The department harbors a variety of methods and styles, a feature that is quite apparent in the present volume. Traditions from theoretical psychology, sociology, linguistics, and religious studies mix with different philosophical traditions. Although most contributions are highly influenced by Anglo-American analytical philosophy, some texts rest on a salient phenomenologi-cal platform (Svenaeus and Bullington). To this comes the rich source of case studies from family medicine presented by Hellström.
We have published this book for two reasons. First, we wish to celebrate that Tema H has existed for 20 years and that it has been a fruitful setting for a broad, cooperative scholarly discussion on the philosophy of medicine and health care. Second, we are now at a stage when several of us will leave (or have left) the department for academic tasks in other institutions in Scandi-navia. It is now timely to write a legacy of our communal efforts.

Lennart Nordenfelt and Per-Erik Liss
Linköping
July, 2002